Next the researchers looked as consumed calories (by subtracting food left on the plates). Without calories labeled the average consumer ate 1,459 calories, with calories that went down to 1,335 and with the 2,000 calorie anchor statement, 1,256.

Ok, that's pretty neat but fascinating?

Here's the really cool part. Researchers then contacted these folks the next day and using dietary recall (yes, it's inaccurate but still useful to see trends) they explored what these folks ate after dinner.

Folks who had menus without calories ate an additional 179 calories, folks with calories labeled ate an additional 294 calories, and those with the anchor statement in addition to calories ate 177 more.

Putting it all together (calories eaten at dinner and then later at home), folks without labeled menu calories ate a total of 1,630 calories, folks with calories labeled ate a total of 1,625 calories and those with the 2,000 calorie anchor statement ate a total of 1,380 calories.

What this research suggests is that if consumers are not made aware of how many calories they burn each day posting calories on menus may lead them to feel they can consume more at home because they chose a "lower" calorie choice when they were out.

Certainly suggests that any menuboard calorie initiative needs to include an educational component. Maybe it's not a huge surprise. Trying to navigate calories without context would be like trying to manage your money travelling without knowing the currency exchange.

Fascinating!

(Interesting sidebar. The American federal labeling bill that's currently being considered does include a 2,000 calorie anchor statement in its requirements. Great comment at the conference by Diane Finegood who pointed out that for many women 2,000 calories daily would in fact cause significant weight gain.)

Wednesday, October 28, 2009

Remember a few weeks ago when I commented on the story that suggested mandatory menu board calories actually increased consumption? I pointed out that the data therein referred to a very specific subset of New Yorkers and likely wouldn't be reflective of a generalizable pattern.

Well, guess what. We've got more data.

Two days ago at the Obesity Society meeting in Washington, the New York City Department of Health presented their preliminary findings.

Looking at 13 different fast food restaurants and over 275 locations the NYC folks analyzed 10,965 receipts just prior to mandatory menuboard labeling and 12,153 receipts in spring 2009. They also had folks complete a quick survey.

What did they find?

In fast food restaurants the number of patrons who reported seeing the information rose from 11% pre-initiative to 56% after, and in coffee shops (like Starbucks and Dunkin' Donuts) the number rose from 1.9% to 54.8%. According to their survey roughly 25% of folks who reported seeing the information reported using the information to help them with their decisions.

Overall it was found that calories did reduce post menuboard labeling. Reductions were found in 11 of the 13 restaurants with one notable outlier - Subway. In Subway calories increased - and they increased a lot, on average Subway patrons consumed 114 calories more post menuboard calories than before.

So does that mean menuboard calories are a dud?

Nope.

Looking at the Subway data researchers found that the increase corresponded with a dramatic increase in the number of foot long subs purchased compared with 6 inchers. The increase likely occurred as a consequence of the $5 foot long campaign. Tellingly however when they looked at the calories consumed per 6 inch and per foot long before and after menuboard calorie posting, turns out that while more footlongs are being consumed, their calories are lower.

Looking specifically at the folks who reported using the information, they decreased their average lunch time calories by 106, though weren't able to decrease much at the coffee shops (a non-statistically significant 14).

There are some limitations to these data. Firstly the economy in 2009 is very different than in 2007 and this in turn may impact on purchasing trends. Secondly the study would fail to capture those people who in response to menuboard calorie posting stopped eating at fast food restaurants. Lastly we're still only talking about fast food. Perhaps in the fast casual restaurants, where there's a greater selection, we'll see different results.

Stay tuned tomorrow for more breaking news on calorie posting and some fascinating work from Kelly Brownell and his friends at the Rudd Centre.

Tuesday, October 27, 2009

I've been meaning to start podcasting for some time and finally I've got around to figuring it out (I hope).

The inaugural episode has me interviewing Dr. Lori Heim, the President-elect of the American Academy of Family Physicians. Just two weeks ago her organization partnered up with Coca Cola to collaborate on educational materials for their website www.familydoctor.org. In return for their involvement Coca Cola is paying the AAFP $600,000.

So what is Coca Cola getting in return? Credibility and trust by association.

In preparing for the interview I went through blog posts and tweets regarding the deal and with almost no exceptions the social media world was up in arms, finding the partnership perverse.

The medical world is no less unhappy and just last week some of the world's most prominent nutritional epidemiologists and advocates sent an open letter to the AAFP asking them to rethink their plans or at the very least lend their name to campaigns supporting soda taxes and the publication of warning labels on sugar sweetened beverages.

In my interview with her, Dr. Heim gave me the sense that indeed, it was all about money and that the partnership with Coca Cola stemmed at least in part due to pressure from AAFP members to sever or reduce AAFP's ties with drug companies.

Personally I think in this case it's one of those situations where the adage, "better the devil you know" holds true. Physicians have a long history of working with drug companies and have a far better understanding both of their products and the methods they use to promote them. As well, Big Pharma has very specific guidelines on what they are and are not allowed to do and say in terms of commercial partnerships and practice. One senior Big Pharma person I know tells me that there are in fact departments within her company to ensure she markets her brands appropriately and she has numerous rules about what she is and is not allowed to do or say in their promotion. Further, the brands themselves have tremendous amounts of research, development and safety testing before they're ever sold.

Contrast those checks and balances with Big Food who have no such testing or obligations to create safe foods and while I have no proof, looking at their advertising I would be very surprised were there any oversight committees worrying about what's being said with the exception of those cases where federal advertising laws mattered or when trying to pretend like they care about children in their hollow pledges not to advertise to them.

None of this is ideal. Ideal would be a situation where the AAFP could be financially self sustainable without external funding. That's not an option, but with this Coca Cola partnership, I think they've bet on the wrong horse.

To hear my interview with Dr. Heim I'm hoping all you'll have to do is click somewhere in this post (and I suspect email subscribers will likely have to visit the blog). If I'm really lucky I'll even figure out how to get it on iTunes.

Monday, October 26, 2009

Sleep deprivation and obesity are unquestionably linked yet the exact mechanism by which lack of sleep leads to weight gain is unknown.

A recent study presented at the Obesity Society's annual scientific assembly may help shed some light.

Any Darukhanavala and colleagues from the University of Chicago designed a small but elegant study. They took 10 overweight volunteers whose pre-study average sleep was 7.7 hours nightly and enrolled them in a two week crossover study whereby for each 2 week period they received 8.5 or 5.5 hours of nightly sleep while all were consuming low calorie diets. Physical activity levels in the groups were identical regardless of hours slept.

While there was no difference in absolute weight loss in this short time period what was striking was the difference in where weight was lost in the two groups. During the weeks with greater sleep 50% of weight loss (as evaluated by DXA absorptiometry) came from fat and 50% from lean tissue (muscle) whereas during periods of less sleep only 25% was lost from fat with 75% coming from lean tissue. Also striking was hunger which was markedly increased in the short sleep arm of the study.

Certainly if these results were applicable to the population as a whole, especially during weight loss efforts, those folks trying to lose weight and sleeping poorly may be losing disproportionate amounts of lean tissue which in turn will disproportionately lower their resting energy expenditure (metabolism) and simultaneously increase their hunger which ultimately may lead them to abandon the effort but not without first losing enough lean tissue to allow them to not only regain the weight they've lost but potentially more.

So yesterday I detailed the results of the Ipsos Reid based milk advertisement that concluded, surprise, that Canadians should be drinking more milk, but buried in the story is the fact that the survey determined that Canadians were not eating enough of any food group according to Canada's Food Guide.

Let me repeat that. According to the survey, Canadians don't eat as much food as the Food Guide recommends.

But wait, aren't 65% of Canadians overweight? And they're not eating as much as the Food Guide thinks they should? I wonder what would happen to the remaining 35% if suddenly they did start eating what the Food Guide recommended.

I detailed ad nauseum (really, it was nauseating how much I detailed it) how the Food Guide causes weight gain - you can read those pieces by clicking herehere, and here, but interestingly this is not the first time I've noticed studies or surveys that reported Canadians don't eat enough according to the Food Guide and that if you did you'd likely gain weight.

The first time I posted on a study published out of Nova Scotia whereby the vast majority of overweight and obese children didn't meet the daily recommended number of servings from the Food Guide.

Here's the second round of data. I received an email from a loyal blog reader named Dana. She attended a lecture put on by Dr. Lise Dubois who presented data from the Quebec birth cohort showing that showing the odds ratio for overweight was 8.8 for 4.5 year old children who consumed 4 grain servings/day. and 7.1 for those consuming 1 serving of meat per day.

Yet Canada's Food Guide recommends 4.5 year olds consume 4 servings of grain per day and 1 servings of meat (thanks for the correction commenters - I had looked at the milk column).

I emailed Dr. Dubois for comment some time ago, but never heard back from her but it would seem to me that according to her data if your 4.5 year old followed the Food Guide's recommendations to consume 4 servings of grain and 1 serving of meat that their risk of obesity would be markedly increased.

Great job Health Canada!

Here's a thought - maybe Food Guides shouldn't be recommending minimum patterns of consumption in a country where it is now abnormal to have a healthy body weight and where research has shown people don't know what serving sizes are?

Just a thought.

(BTW, I checked with Ipsos Reid - the way this survey was conducted was that people reported the quantities of food consumed and then dietitians calculated the number of Food Guide servings therefore you can't make the argument that in the survey Canadians just didn't know what a serving size wise, and while I can't claim it with certainty, I'd be very surprised if Dr. Dubois' research was any different in that I'm certain she knows what a Food Guide serving represents)

Wednesday, October 21, 2009

According to my friends over at Fooducate, at this week's American Dietetic Association (ADA) conference there was a talk regarding whether or not we can trust industry sponsored nutrition research. The reason that's in question is because sadly right now there are no guidelines in place to help expose conflict of interest in dietetics. It was the absence of such guidelines which led Marion Nestle in 2001 to write a fascinating journal article about how food company sponsorship impacts on the profession's credibility. Ultimately it led Marion to resign her ADA membership. According to Fooducate,the lecture was not a popular one at the ADA conference and was very poorly attended.

Of course it's not just research articles that demonstrate conflicts and bias, we can see non-evidence based industry bias in a far more dangerous place - the mainstream media.

Case in point?

Yesterday there was a CBC report about an Ipsos-Reid survey which according to the CBC was, "conducted on behalf of Dietitians of Canada" (DC). What the CBC article later reported was that the survey was cosponsored by the Dairy Farmers of Canada. The DC and Dairy Farmers of Canada joint press release on the survey drew these 4 conclusions (highlighting is mine, not theirs):

"1. Consumption of all four food groups is far below recommended levels;

2. A significant number of Canadian adults had not consumed any milk and alternatives or any vegetables and fruit on the day prior to the survey.

3. Many Canadian adults report they have barriers to healthy eating.

4. A majority of Canadian adults are not aware of the many health benefits of milk and alternatives and vegetables and fruit including their role in reducing the risk of some cancers, hypertension and other chronic diseases.

5. When made aware of these important health benefits, Canadians report they are motivated to increase their intake of foods from these food groups."

Looking at the actual survey the bias is obvious. The only specific questions regarding choices and healthfulness have to do with either "dairy and alternatives" or "fruits and vegetables" and of the 5 conclusions of the press release, 3 directly relate back to dairy (2, 4 & 5). Absent was information regarding the health benefits of whole grains, nuts, legumes or fish.

The thing is I get it. I fully understand why the Dairy Farmers crafted the survey - it was designed to report that Canadians don't drink enough milk; that there are umpteen-million magical "benefits" to milk consumption; that milk's as healthy and important as fruit and vegetables; and that if we just teach people more about unbelievably healthy milk they'll drink more of it, but the question I've got is why do you think the Dietitians of Canada decided to lend their name and credibility to a survey that ignored multiple food groups and is basically a milk advertisement?

Unfortunately the media certainly treated it like more than simply a milk ad and they ran with it prominently featuring DC's involvement. Had the poll simply been one from the Dairy Farmers of Canada I imagine the coverage of the report, if any, would likely have been very different. As well in this case, the media also oiled the slippery slope of corporate dietetic collaboration by failing to identify quoting dietitian Kathy Furgala's corporate allegiances referring to her instead as a "Toronto-based dietitian". Frankly it was in fact Kathy's quote from the CBC story that got me riled up enough to write this post and explore the survey in the first place. She was quoted as saying,

"For people who say, 'I don't want to worry about the food groups,' just look at your plate, and see if you can't throw in one veggie or some cheese"

Yup, the two most important things you could ever add to your plate if you don't want to "worry about the food groups" - a single vegetable or of course, some cheese.

I'm not sure what's worse. DC signing off on a milk ad disguised as a national eating survey, a dietitian who would give the advice that all your plate needs for your meal to be healthy is one lonely vegetable or a hunk of cheese, or a reporter who chooses to identify that dietitian as a "Toronto area dietitian" while omitting the fact that she's in fact a nutrition educator for the Dairy Farmers of Canada in an article whose focus is on increasing dairy based on the results of a survey paid for by the Dairy Farmers of Canada.

[Oh, and in case you noticed - the survey found that "consumption of all 4 food groups is far below recommended levels". Strange in a country where over 65% are already overweight or obese. Could it be that the recommended levels recommend too much? Tune in tomorrow for more discussion.]

Nestle, M. (2007). Food company sponsorship of nutrition research and professional activities: a conflict of interest? Public Health Nutrition, 4 (05) DOI: 10.1079/PHN2001253

Monday, October 19, 2009

I'm not sure how I found myself clicking over there, but one day last week I landed up on the webpage for Canadian Health Magazine - a magazine published by the Canadian Medical Association (CMA).

I can't remember what I was looking for, but I sure do remember what I found.

I found a series of banner advertisements by a company named A. Vogel. Head over to their webpage and you'll find they're all about, "phytotherapy and homeopathy".

Now before you get all in a huff, I've got nothing against any form of therapy - so long as the intervention you're promoting actually has an evidence-base. Prove it works and I'll happily endorse it, but if you can't, at best its prescription is premature and hopeful and at worst, risky and fraudulent.

So what did the banner ads on the Canadian Medical Association website want to sell me and what wording did they use to try to do it?

Echinaforce Junior - Get your kid's immune system ready!

Echinaforce Junior - To prevent or relieve cold and flu.

Echniaforce Junior - Clinically Proven.

Echniaforce Junior - Boost kid's immune system throughout winter.

I'll get to the details behind the claims in a minute but first this - I noticed that there was an "advertising" link on Canadian Health Magazine's site so I clicked it and learned that with over 30.3 readers per copy Canadian Health Magazine is the most read magazine in Canada and 77% of readers said the content of Canadian Health Magazine was more credible because of CMA ownership.

Those are some truly impressive statistics!

I also learned that the editorial positioning of the magazine suggests it's meant to,

"deliver the most credible and current health news and research information to Canada’s health consumers"

So back to Echinaforce Junior.

Echniaforce Junior is simply Echniacea. Looking at medline, since 1950 there have been 24 papers published that discuss the therapeutic use of Echniacea and many of these are simply commentaries and not in fact therapeutic trials. Given the advertisement's claims that Echniaforce Junior would help protect your children by preventing influenza, and given the state of alarm due to H1N1, I decided to look for studies that suggested echinacea had an impact on flu frequency, duration or severity.

Guess what? There were none. The closest I could find was a paper published in what I would consider a dubious journal already, the Journal of Alternative & Complementary Medicine, but putting my instinctual skepticism aside I read the paper and learned that the researchers only investigated symptoms suggestive of either cold or flu and did not in fact test subjects to determine if they were suffering from influenza in the first place.

So to summarize the vast dearth of research, there is not a single published study looking at the use of Echinacea for the prevention or treatment of influenza, yet of course that's what the advertisement tacitly endorsed by the Canadian Medical Association, in a periodical where 77% of readers report having more trust due to CMA ownership, quite explicitly states Echniacea does.

Regarding colds and Echinacea, there's a bit more detail as there have in fact been multiple studies looking at Echinacea's utility in treating the common cold. The most robust such study was published in 2005 in the New England Journal of Medicine where researchers studied 399 volunteers who were challenged with rhinovirus. The results? Nada. (For a brief review of some of the other Echinacea cold studies you can head over to the Canberra Journal)

So in short there's nothing in the medical literature to suggest that Echinaforce Junior could deliver on any of its claims.

Clearly, if there is an editorial policy for vetting CMA owned Canadian Health Magazine advertisements it's not being followed as it's inconceivable to me that a Canadian Medical Association advertising policy would allow for the advertisement of unproven products that prey on medical fears. Sadly what is wholly conceivable to me is that they have no advertising policies whatsoever and hence are in fact contributing to healthcare fraud. Worse yet is the Canadian Medical Association's potential contribution to pediatric mortality as parents who decide to choose Echinaforce Junior (in part perhaps due to their increased trust of its association with the Canadian Medical Association whose mission they know is to deliver "the most credible health news" to Canada's health consumers) over vaccination for flu prevention certainly have no medical evidence upon which to support their choice.

I've copied this post to the President of the CMA and the editor of Canadian Health Magazine and I sincerely hope the offending ads are immediately removed from their site.

Will keep you posted as to responses.

UPDATE: The CMA is looking into the ad in question (among a few others) and certainly agree that their responsibility to ensure the validity of the claims of their advertisers is greater than that of the average company.

Thursday, October 15, 2009

One that comes regularly is a trade journal called The Medical Post, and in it the Dairy Farmers of Canada are regular advertisers making half page buys geared to look like articles that they entitle Nutrition and the Physician. These pieces in turn are generally written or at the very least attributed to physicians, professors and dietitians highlighting some benefit of dairy consumption.

For a long while the bulk of these medical advertisements were about milk's role in weight management but that died off shortly after Big Milk in the US agreed with the Federal Trade Commission that claims regarding milk and weight loss/management were preliminary at best.

The most recent version I read was about milk products and the prevention of colon cancer and it is attributed to Dr. Parviz Ghadirian, the Director of the Epidemiological Research Unit at the Hotel-Dieu hospital in Montreal and a Professor in the Department of Nutrition at the University of Montreal.

The advertisement rightly points out that there is indeed some evidence to suggest a modest risk reduction for colorectal cancer with the consumption of diets high in dairy.

So what's my problem?

I've got a few.

Let's start with the opening paragraph where Dr. Ghadirian quotes from the World Cancer Research Fund report, "milk probably protects against colorectal cancer". The quote is true, I looked it up. Problem here is that it's not the full quote. The full quote reads,

"The strongest evidence, corresponding to judgements of ‘convincing’ and ‘probable’, shows that milk probably protects against colorectal cancer, and that diets high in calcium are a probable cause of prostate cancer"

Oh, and about calcium, next I looked at the meta-analysis Dr. Ghadirian referred to which demonstrated a 22% risk reduction in adults who consumed higher quantities of milk. In it I learned that calcium supplementation alone confers a virtually identical risk reduction (and in fact slightly greater) to that seen with milk products as noted by the authors in the paper's discussion,

"Interestingly, both dietary and supplemental sources of calcium showed inverse effects, with the latter reducing colorectal cancer risk by 24%"

Strange how Dr. Ghadirian's advertisement doesn't mention that fact.

Next I pulled the large prospective cohort study he referred to which demonstrated a 28% colon cancer risk reduction in women who consumed higher quantities of milk products and 15% in men. In it I learned that the results showed that in men dairy intake did associate with lower colorectal cancer incidence but again was positively associated with prostate cancer. Interestingly while the relationship between calcium supplementation and decreased colorectal cancer risk held in men, in this study non-dairy calcium supplementation did not increase prostate cancer risk,

"dairy food intake was inversely associated with cancers of the head and neck, esophagus, stomach, colorectum, and bladder, whereas it was positively associated with prostate cancer"

"Total calcium intake was significantly related to a lower risk of colorectal cancer and showed a weak inverse association with kidney cancer. On the other hand, total calcium intake was not related to prostate cancer."

Next I pulled the pooled analysis he refers to and once again the pooled study's findings were applicable both to plain old calcium supplementation as well as milk but interestingly they pointed out something else,

Let's take a look at the World Cancer Research Fund's report on cheese - did they find it might increase colon cancer risk? Yup.

"There is limited evidence suggesting that cheese is a cause of colorectal cancer."

Hey, isn't cheese a milk product?

So what did Dr. Ghadirian's medical advertisement say on cheese,

"A study using the Swedish Mammography Cohort of 60,708 women that included approximately 15 years of follow-up suggests that consumption of higher fat milk products (especially cheese) and the CLA in dairy fat are also important in reducing risk."

Pulling the Swedish study one learns that the researchers weren't clear on why their results on cheese differed from everyone else's and they hypothesized that it might have to do with the fact that their cohort ate a tremendous amount of cheese and admit that the differences in their diets don't stop there leading me to wonder if perhaps they're not the greatest population upon which to draw global, or at least North American, conclusions.

To summarize the actual medical literature used by Dr. Ghadirian: Milk products decrease the risk of colon cancer to a degree pretty much identical to that seen with calcium supplementation but at the same time in men increases their relative risk of prostate cancer, while diets high in cheese potentially increase colon cancer risk except in Sweden.

My advice to my dear readers? If you read anything sponsored by the Dairy Farmers of Canada you'll probably want to read the studies themselves before drawing any conclusions, and if Big Milk comes a' knockin' on your door asking you to write one of their medical advertisements tell them, "no thank you" and while you might lose a few bucks of chump change (literally perhaps), at least you'll keep your ethics.

And here I'm really at a loss. Dr. Ghadirian is a world class researcher and epidemiologist. How is it that he agreed to put his name on an advertisment that omits such highly pertinent data?

"when seeking life advice to go to people who are required by law to get their information from the most credible sources and held accountable for the information they dispense"

I couldn't agree more - so let's talk about the information you recently dispensed.

In a recent advertisement gussied up as a pretend newspaper article with the lead recommendation of,

"Research shows that two to three servings of milk products each day, included as part of a balanced diet and active lifestyle, are vital in maintaining our families’ health."

Shannon is quoted as stating,

"I personally am a great lover of chocolate milk. It has a bit of added sugar to it but all those essential health benefits are there and as long as it is part of a healthy diet, that extra sugar should not do children who shy away from ordinary milk any harm.”

A "bit" of added sugar Shannon? Per cup of your client Gaylea's 1% chocolate milk there are nearly 5 teaspoons of added sugar. If unsuspecting parents followed your advertisement's advice to give their children a "harmless" 3 glasses of chocolate milk a day that's now 15 teaspoons of added sugar, not to mention the sugar already in the milk. In total those children will be consuming 23 1/4 teaspoons of sugar a day - 3/4 of a teaspoon shy of half a cup.

Want to know what else they'd be drinking Shannon? They'll also be drinking 600mg of sodium (who would have thunk chocolate milk had so much sodium - um, maybe a dietitian working for the company who makes the product?), or a full 1/2 of the total recommended daily maximum for kids under 8 and 40% of total recommended daily adult maximums.

But wait, there's more. They'd also be downing 540, not satiating, liquid calories a day, or roughly the same amount they'd get if they were chugging 1.5 daily litres of Coke.

Doing the math - a year's worth Shannon's advice would have your kids drinking just over 90 pounds of sugar, that's eighteen 5lb bags, as well as 2 full cups of salt and 54lbs worth of calories.

Fantastic advice Shannon. So glad we've got "credible sources" of information like you to help us navigate as you put it on your website, "the incredible amount of myth and misinformation", because surely it's just a myth that chocolate milk is an unhealthy choice, and advertisements dressed up as newspaper articles with quotes from registered dietitians stating that magic nutrients in milk make the daily consumption of 1/2 a cup of liquid sugar and far too much sodium and calories a-ok, are meant to help, not misinform.

Parents, think of a glass of chocolate milk like a liquid chocolate bar. If you think giving your kids a Hershey's bar with each meal is a good plan, well then you and Shannon would probably get along great. If not, consider it a sometimes food.

Tuesday, October 13, 2009

Dr. Barr is a professor of nutrition at the University of British Columbia and she has had a truly illustrious career, having published dozens of peer reviewed articles. She's also been a workhorse for the milk industry serving as a member of the Medical Advisory Board of the Milk Processors' Education Program, the Medical Advisory Board for the International Dairy Foods Association and speaking and writing regularly for the Dairy Farmers of Canada.

So what's got my knickers in a knot about Dr. Barr? It's her quotes from the recent "article" published in CanWest papers across the country last week where she tries to make the case that increased dietary dairy consumption reduces blood pressure. I put the word article in quotations because CanWest reports that the articles are "a joint venture with Dairy Farmers of Canada"and refer to them as a "special advertising feature".

"The findings showed that those on the fruit and vegetable rich diet experienced a significant reduction in blood pressure. Those on the diet with milk products as well showed an even more significant reduction."

A true statement, except of course it omits the fact that the study was not designed to examine the specific effects of dairy on blood pressure and more importantly omits the fact that the diet with dairy had other differences from the fruit and vegetable rich diet including lower overall saturated fat, lower total fat and lower cholesterol.

Looking at the last 15 years of clinical trials research I was able to find only a handful of studies that were specifically designed to investigate the effects of dairy on blood pressure, and of those none were large or robust enough to draw firm conclusions.

Thankfully I was able to find a recent review article published in the Journal of the American College of Clinical Nutrition which summarized the most pertinent studies detailing dairy's effects on blood pressure. The review reported that a few studies indeed showed decreases in blood pressure with increased dairy, another showed increases in blood pressure with yogurt but not cheese, and many showed no dairy/blood pressure relationship at all. Regarding the DASH study the review specifically concluded,

"The greater reductions in BP seen with the DASH diet compared to the high fruits and vegetable diet cannot be ascribed to dairy products per se"

and the review goes on to conclude that there are certainly some plausible mechanisms by which dairy might improve blood pressure and that further research is warranted.

It was this. The review article summarized the only studies that have ever been published that were designed specifically to address whether or not an intervention involving increasing dairy would have a positive impact on blood pressure, all 5 of them. According to the review none of those studies showed significant improvements to diastolic blood pressure while 3 showed minor improvements to systolic pressure, the greatest of which was 5mm Hg.

Again, so? So why are you so pissy you're actually devoting an entire post to Dr. Barr and suggesting she's "bared her bias", yeah it doesn't look like there's much data to conclusively recommend increasing dairy for blood pressure benefit, but so what, at least there's some?

This study, conducted in the year 2000, followed 204 healthy, middle aged men and women and tracked what happened to their blood pressure and their weight following randomization to either stick with their current diets (low in dairy) or to add 3 glasses per day of milk to their diets for 12 weeks. At the end of 12 weeks researchers found that the increased dairy group did not see any statistically significant reduction in their blood pressures (nor did the subgroup of pre-existing hypertensives in the sample), but they did see statistically significant increases in weight, triglycerides and blood sugar - not exactly healthful results.

Want to know who the lead author of this study, one of only 5 studies ever published which was actually designed to determine the effect of increasing dietary dairy consumption on blood pressure, the results of which showed increasing milk not only failed to have a positive effect on blood pressure but rather, significantly worsened weight, triglycerides and blood sugar? You guessed it, Dr. Susan Barr.

Ain't it funny (and by funny I mean awful) that she didn't mention the paucity of conclusive research linking increased dairy with decreased blood pressure along with her own study's negative and potentially harmful results while misrepresenting the findings of the DASH study in the "article", I mean "joint venture", I mean "special advertising feature" meant to sell more milk?

Monday, October 12, 2009

Ok, clearly that's not all I can say...the other day I was estimating the number of words I've typed these past 5 years on this blog and figured it was near a million.

Here are some words that Horizon has to say on their carton,

"Helps Support Brain and Eye Health

Kids' brains grow incredibly fast. In fact the brain nearly quadruples in the first five years of life. Up to 20% of the human brain is made of DHA, yet most kids don't get their recommended DHA from common dietary sources like fish. By making Horizon Organic Milk Plus DHA your family choice, you're bringing home all the goodness of organic plus an extra nutrtional boost for growing mids and bodies"

So how much DHA do you get per glass of this miracle brain milk?

32mg.

According to the Center for Science in the Public Interest 32mg of DHA is less than what you'd get from a single bite of salmon.

My recommendation?

Save your pennies by not buying this badvertised milk and use them to buy your kids at least one weekly serving of fish instead.

Their brains (and yours) will thank you.

(Oh, by the way, it's milk week here at Weighty Matters and also thanks to Hemi from Fooducate for tracking down the mg of DHA)

Thursday, October 08, 2009

Readers of this blog will certainly be aware that the EU has clamped down on unsubstantiated food health claims and as I mentioned a few days ago, two of those claims have resulted in Danone spending $35 million in the US to settle a class action lawsuit.

Well the EU's health claims team just released their first round of rejections. According to the excellent industry newsletter Food Navigator of the 500 claim dossiers submitted more than 2/3 were rejected as not providing sufficient evidence to support the claims being made.

With regards to yogurts - the happy home of many probiotics, Food Navigator reports,

"Out of 100s of probiotic strains, not a single one was shown to have gut health, immunity or any other benefits."

So riddle me this fair reader, why then in my supermarket last night was I able to find yogurt claims for,

So really, I'm asking the question. Do any of you readers have any idea why it is that health claims refuted by the European Union and successfully removed via a class action lawsuit in the States are still selling food here in Canada?

Wednesday, October 07, 2009

On July 18th, 2009 New York City's mandatory menu calorie law went into action and restaurants with 15 or more locations were forced to post calories on menu boards and/or menus for their patrons.

The hope has always been that armed with this information people would choose fewer calories.

Well, so far the results aren't too promising - at least not for a very specific population.

In a paper published online in the journal Health Affairs, Brian Ebel and colleagues explored the purchasing behaviour of 1,156 adults at 4 different fast food locations in New York City. Researchers tracked purchases 2 weeks prior to the labeling law's implementation and 4 weeks after its implementation. Participants were told before purchasing that if they provided researchers with their receipt and answered a brief survey that they would receive $2. Prior studies using similar methodology for recruitment reported roughly 55% of restaurant goers participate. Researchers then used the receipts to determine the calories of the menu items ordered.

The population studied was quite distinct. 85% were from minorities, and half had only a high school diploma or less education. The neighbourhoods were poor neighbourhoods and on average respondents reported that they frequented fast food restaurants an average of 5x weekly.

What the researchers found was that for this sampling of poor, uneducated, fast-food addicted, minorities unless they specifically stated that they both noticed calories on the menu boards and changed their behaviours accordingly, calories consumed were the same both before and after the labeling law came into effect.

Given the sample, these data are clearly not necessarily representative to the rest of the population. I would also expect that there will be far less change in caloric purchasing in fast food restaurants with fairly limited menus than in fast casual restaurants with more varied fare and patrons with more disposable income. Looking at McDonald's menu specifically, there really isn't much variety in calories in that even salads, when combined with dressings, tend to have calories comparable to their burgers. Furthermore given the nature of the sample and the recruitment I wonder whether or not they selected for the poorest of these poor patrons who actually would bother taking time out of the middle of their weekday for $2.

The authors also admit that because the study took place so soon after the law went into effect perhaps they hadn't had enough exposure to have the numbers sink in. Personally I suspect that the exposure that truly would be necessary wouldn't be the actual calories on the menu boards but rather exposure to education as to just how many calories the body needs per day and in fact there have been studies that suggest menu labeling works far better when combined with that type of information.

At the end of the day what this study tells me is that cost matters to this group far more than calories, and pragmatically I don't blame them one bit. It also impresses upon me the real need of finding innovative means to provide affordable, healthy food for the poorly educated and impoverished.

So should we shelve these initiatives?

Of course not, though it will certainly make the results from the much larger sampling of 12,000 receipts being collected by the public health department of New York that much more interesting.

It's still a hill I'd be willing to die on.

Brian Elbel, Rogan Kersh, Victoria L. Brescoll, & L. Beth Dixon (2009). Calorie Labeling And Food Choices: A First Look At The Effects On Low-Income People In New York City Health Affairs

Tuesday, October 06, 2009

Today I'm going to offer you a list of things I feel are worth acting on. While certainly you may not agree with the order or even every item on the list, surely there'll be at least one or two hills here that you may want to take stands on and as far as I'm concerned these are 10 nutritional hills worth dying on.

1.An evidence based Food Guide.

While the Food Guide may not be taped on every fridge it's still hugely important. It helps to shape national nutrition policies and industry programs, and serves as the backdrop against which every food related news story is published. It is what's taught to our children in schools, it dictates what's served to patients in nursing homes and hospitals, it becomes the basis for industry based food health claims and front-of-package labels. In short it becomes Canada's nutritional consciousness and given how infrequently it's revised (15 years this past time around), if it's wrong it'll misinform and undermine good nutrition in Canada for a decade or more.

And really, errors? Pardon me but how the !*&# can there be errors in a document that should simply be a reflection of our best available evidence and moreover, how the !&*# did it take them nearly 2 years to churn out the piece of drek we're now stuck with?

I truly believe that the noise and negative coverage surrounding the launch of the 2007 Food Guide has served to pave the way for a robust overhaul the next time around. Your job is to point out the Food Guide's unacceptable weaknesses whenever possible and promote its early review.

Canada is one of very few Western nations that does not support a publicly funded national meal program for its students. It has been shown that school food programs markedly improve the mental and physical well being of students who utilize them with some reporting increases in standardized test scores, less illness, better discipline and improved alertness. According to Canada's Chief Medical Officer of Health,

"When children go to school hungry or poorly nourished, their energy levels, memory, problem-solving skills, creativity, concentration and behaviour are all negatively impacted. Studies have shown that 31% of elementary students and 62% of secondary school students do not eat a nutritious breakfast before school. Almost one quarter of Canadian children in Grade 4 do not eat breakfast daily and, by Grade 8, that number jumps to almost half of all girls. The reasons for this vary – from a lack of available food or nutritious options in low-income homes, to poor eating choices made by children and/or their caregivers. As a result of being hungry at school, these children may not reach their full developmental potential – an outcome that can have a health impact throughout their entire lives"

Reading his words one can only hope that in the backrooms he's vigorously lobbying for such a program and so should you.

3. A national trans-fat ban

Marni Soupcoff's personalized and juvenile arguments from the National Post two days ago notwithstanding, trans-fat is an unnecessary food additive that is toxic in any amount. Not only would removing it from the food supply directly impact on reducing unnecessary deaths, but studies also suggest that its removal will also have the indirect benefit of causing an increase in healthy fats consumed.

It's estimated that 6,000 Canadians die annually as a consequence of trans-fat in our food supply and Canada's asinine 2 year free pass monitoring program has proven that industry as a whole is not in fact uniformly removing it.

Your job - again, support the ban, shoot down moronic discourse like Marni's by pointing out that it's not a matter of nannying for the state to suggest we remove a toxic food additive that has less/non toxic alternatives, and call your MP to let them know you support Mme Gelinas' Private Member’s Bill 156, Healthy Decisions for Healthy Eating Act.

4. Mandatory menu-board calories

Plainly put, calories are the currency of weight. Given that it is now no longer normal to have a healthy body weight (between 60-70% of North America is now overweight or obese) interventions geared towards educating the public about energy are crucial. Perhaps none are more important than menu-board calories as it has been shown that not only do people make different choices when faced with menu-posted calories, but restaurant chains respond to the subsequent customer demand for lower calorie choices by designing new lower calorie options and modifying older higher calories ones. Given the 54% of our food dollars now go to food eaten outside of the home, clearly this is a huge hill.

It's important to point out here that this hill isn't an "anti-calorie" hill, it's a pro-education hill. You can't roll out an intervention like this one without a concomitant campaign that educates Canadians about how many calories their bodies need per meal, per snack and per day, a campaign which would lend itself handily to a web-based energy expenditure calculator page. The calories are not meant to be used for judgment, just guidance similar to the way consumers currently utilize price tags to guide their purchasing decisions. (Update: More on this tomorrow to discuss recent finding that in the poorest neighbourhoods in the US, this doesn't seem to help)

Your job would be to support mandatory calorie postings by means of speaking up and countering the hollow arguments that tend to suggest that it will be an anti-calorie campaign, to speak to your school boards to support the Ontario Medical Association's call to put calories in school cafeterias and if you're in Ontario to call or write your MP and let them know you support Mme Gelinas' Private Member’s Bill 156, Healthy Decisions for Healthy Eating Act that calls for both mandatory menuboard calories as well as a trans-fat ban.

5. The establishment of soda taxes

There's zero doubt that sugar-sweetened beverages are a major contributor to the current default annual weight gain of society. There's also no doubt they contribute to the burden of societal chronic disease. Nanny state alarmists tend to try to paint soda taxes as a draconian cash grab and an infringement of civil liberties, but really what's being called for is a nominal tax on beverage manufacturers for each ounce of sugar-sweetened beverages produced. The most recently proposed amount was a penny an ounce which would raise the cost of a can of soda by roughly 12 cents. Hardly a huge amount of money for each individual but likely to generate well over $1 billion annually in Canada which if utilized to fund such things as a National School Food Program, would be an unbelievably beneficial tax (and according to studies would also result in a 10% decrease in national soda consumption).

Your job - think critically about it, challenge the folks who kneejerk when they hear the word tax and if the opportunity ever arises that we're actually considering this as a federal program, call your MP and tell them what you think.

6. A robust and evidence-based front-of-package labeling program

To quote from the movie Highlander, "There can be only one", or at least that's how it should be. The glut of front-of-package labeling dilutes the utility of all of them, and given all of Canada's options are awful, we're really behind the eight ball here where at least in the States there are two evidence-based, shielded from industry options to consider - Hannaford Brothers' Guiding Stars and my personal favourite, Nuval.

Frankly I think zero options would be better than our current Canadian options and consequently I would certainly support a ban on front-of-package labels though of course my preference would be to not reinvent the wheel and instead for the government to provide incentives to supermarket chains to license the Nuval algorithm and score every single item on their shelves (as is being done in American Price Chopper, Hy Vee and Meijer stores).

In case you're not sure what Nuval is, it's an algorithm developed by some of the world's leading epidemiologists and nutritionists that generates a weighted score of 30 different nutrients and yields a number between 1-100. Dead simple to use, the higher the number, the healthier the food. Incredibly useful as most people don't have the background or the time to properly evaluate food labels.

Given that's a pipe dream perhaps the best you can do is to educate your colleagues, friends, families and patients about the uselessness of current Canadian front-of-label programs and were the opportunity arise, introduce them to our healthier American alternatives.

7. A ban on school/hospital/civic junk food

Do we sell cigarettes in schools, hospitals, community centres, hockey arenas and libraries? No? That would be crazy? How is that any crazier than selling foods with mind-numbing amounts of sodium and/or trans-fats that are unquestionably contributors to the growing burden of chronic diseases in Canada?

The only possible reason for their sale in such centres is profit, but given we live in a country with socialized medicine, I would argue that the sale of disease-inducing garbage to our children in our schools, community centres, hockey arenas and libraries almost certainly cost society more in long-term consequences than the profits they generate at point of sale. Of course that also assumes that one can't sell healthy foods for profit which is an idiotic and defeatist attitude.

The fact that children have to complain about the hypocrisy of the foods their lunch room serves versus the foods they're taught are and aren't healthy before they see change is unconscionable.

This of course goes hand in hand with the development of a national school food program but given that I don't see that one coming down the pipes anytime soon for now I'd argue your job is to meet with school principals and superintendents, write letters to the editor, go on clandestine trips with cameras and shame people into action. Profits should not be made or considered on the backs of our children's health.

8. A national ban on advertising targeting children

Plain and simple, young children are not able to discern the difference between truth and advertising and consequently I believe it's entirely unethical to allow marketers to target them. Furthermore food, and specifically unhealthy food, is the number one source of television commercials seen by children. Frankly to me whether or not they impact childhood obesity rates (they do) is besides the point as I think targeting children period is unethical.

Currently I'm not aware of any politicians considering an advertising ban. Until then, have discussions with your children's schools regarding the inclusion of courses meant to teach kids how to critically analyze commercials and certainly, even at a very young age, start teaching them yourselves. Our 5 year old certainly knows what commercials are and what they set out to do (though she still wants me to buy her some Cinnamon Toast Crunch).

9. A robust natural products directorate

The need for this was highlighted last week in Macleans magazine where it was revealed that,

"products can obtain a federal licence number—what surely looks to consumers like a government seal-of-approval on the label—on the basis of old beliefs",

the translation of which means that if someone, sometime, somewhere was using pine needles to treat herpes then you can bottle up all the needles you want and sell them, absence of evidence be damned, to any one you damn well please, all with the government's blessing.

I think Macleans' John Geddes hit it right on the head when he stated,

"It has never made sense to me that Health Canada is validating traditional-use claims. Health Canada should be in the business of applying science to regulation."

No indeed, it doesn't make sense.

In terms of what you can do, currently Health Canada has set a 2010 deadline of licensing all Canadian natural health products. Why not take a moment or two to write your MP and tell him how you believe that licenses should only be granted on the basis of robust evidence supporting the claim as otherwise all Health Canada will be doing is perpetuating health care fraud.

10. A robust food health claims division

To be honest, I'm not entirely clear on the process we have right now. Here's what I do know:

I know Danone (Dannon for my American readers) recently withdrew its health claims regarding the probiotics it puts in Activia (regularity) and Danactive (immunity) from consideration in the new, stricter, European Union health claims commission. I also know Danone recently settled a class action lawsuit regarding those same claims in the US to the tune of $35 million and I know that yet here in Canada Activia and Danactive are still being actively marketed with their EU retracted and US sued claims intact.

I know with Nestle we've got the Canadian Food Inspection Agency asking Health Canada to revoke the right of infant formula makers to brag and make health claims about their DHA additions unless those additions are included in amounts consistent with the benefits seen in medical literature. And I know that Similac Advance doesn't meet those amounts and yet still reports it's DHA inclusion will help baby's brain and eyes develop. I know Health Canada by the way took a pass on CFIA's request.

Lastly I know that according to CBC's Investigative Consumer show Marketplace one would have to consume 214 slices of Wonder Bread Head Start to get the equivalent amount of DHA as would be found in 75grams of salmon yet Wonder Bread Head Start still actively targets parents with their promises of smarter kids with statements like,

"Give your little ones a headstart! New Wonder+ Headstart has the fresh Wonder taste they love PLUS all the benefits of Omega-3 DHA which helps in the normal development of the brain, eyes and nerves."

Clearly if we actually have a system, something's very wrong with it. In terms of what you can do about it, here I'm a bit of a loss. I'm really unsure who to complain to if the CFIA gets ignored by the folks over at Health Canada. Here I need enlightenment and certainly if you're reading this, and happen to know who/how/why things get done the way they do with health claims in Canada, leave a comment for me and my readers to help me mobilize thoughts and efforts.

So there you have it - my top ten list of nutritional hills worth dying on. Such an incredibly sad statement that we need to actually fight for any of these causes given that a Health Canada truly dedicated to the health of Canadians would have had them all covered ages ago and done our fighting for us.

Monday, October 05, 2009

Industry always takes the blame for our current toxic food crisis. People point fingers and give the evil eye to fast food giants, soda pop makers and the purveyors of junk food, and while I may at times point fingers at them too you'll notice that it's not the products they produce and shill that I'm pointing at, it's the unethical manner in which they market them.

Industry doesn't deserve the blame for our current nutritional quagmire, they're just doing what they're in the business to do - sell food. They are not in the business to protect, promote or pander to our health.

So who do I think deserves the blame?

Maybe you.

Maybe you because if you're reading my blog then you clearly care about nutrition and health, and so maybe you because I blame our current nutritional quagmire on the folks whose jobs it is to keep us healthy and educated who despite knowing better prefer to stay silent than to rock the boat.

I blame the health professionals who time and time again refuse to speak up against non-evidence based national nutritional policies, the educators who allow school cafeterias to sell foods they themselves teach their students to avoid, the hospital administrators who allow the likes of Burger King and Pizza Hut to set up shop on their main floor or ignore the no-name junk food their own cafeterias excrete, and the regulators, civil servants and politicians who sit idly by while corporations make blatantly false claims about nutrition or weight, or eagerly target our youngest most vulnerable consumers, and yet continue to sell and market their products with impunity.

And so if you fit in any of those categories and you stay silent in the face of things you know to be false, or misleading, or non-evidence based, well then I blame you.

And why the silence? I can think of multiple possible reasons. Reasons such as fear, profit, laziness, greed, politics, and apathy, but really how do you go to sleep at night if you're letting any of those reasons usurp evidence in the metering of your own public health actions and stands in fields you yourselves purport to care about?

The most recent example? Last week the Quebec Coalition on Weight-Related Problems (Coalition Québécoise sur la Problématique du Poids) released a report vilifying front-of-package labeling programs. They rightly condemned Pepsi Co.'s Smart Spot, Kraft's Sensible Solutions and Old Dutch' Snack Wise as being misleading. What front-of-package program did they leave out of their analysis and presentation? Why the most heavily promoted and well known front-of-package program in Canada - the Heart and Stroke Foundation's Health Check.

Why did they leave it out?

Well on Friday I spoke with the Coalition's Director Suzie Pellerin and she told me they ignored Health Check for two reasons: Firstly because they were only looking at "private" programs and secondly because Health Check is "based on Canada's Food Guide".

The Food Guide? Fantastic, it must be great then, right, why even bother looking at the program? I'll tell you why Suzie, you should look at it because the fact is the Heart and Stroke Foundation's name fosters tremendous trust in consumers and if Health Check were in fact built on shaky nutritional foundations it would make it a far more dangerous program than Pepsi Co. and others' where the notion of buyer beware may in fact register among shoppers. On the other hand, if it were a wonderful program, had you actually evaluated it you could have used it as contrast to show how woefully deficient the industry's programs are when compared to a "based on Canada's Food Guide" approach.

Truth be told, Health Check is abominable. It's a front-of-package labeling program that grants its heavily trusted, and even more heavily promoted, seal of approval to lowest common denominator processed foods. Health Check allows participating products to contain up to 5% trans fat, milk to be sweetened with so much sugar that it contains double the calories and sugar of Coca Cola, the provision of more than a third a child's daily sodium allotment in a single item, and it puts no limits on juice consumption, doesn't differentiate between whole grains and refined, ignores the concept of calories and it is complicit in the sale of highly processed foods to children using Disney cartoon characters.

And truth be told, Suzie and the Coalition knew all about these non-defensible issues with Health Check as I know they regularly read my blog, and frankly even if they didn't, their initial survey was done by dietitians who certainly have the means with which to critically evaluate Health Check's lacking nutritional criteria.

So why do I think they didn't speak up?

Silence and/or blind faith. Wilful silence because perhaps they felt they couldn't afford to upset the Heart and Stroke Foundation, one of the Coalition's partners, and perhaps for those Coalition members who don't read my blog, blind faith in that the Heart and Stroke Foundation, like Canada's Food Guide is blindly considered by many to be sacrosanct and beyond reproach.

Sadly, it's not just the Coalition.

Where are the voices from the Canadian Diabetes Association in denouncing the Food Guide for not ensuring that its call to action on diabetes-inducing refined grains is to minimize their consumption while maximizing diabetes preventing whole?

Where are the voices from the Canadian Cancer Society in calling for a revision of the Food Guide's meat recommendations to be consistent both with our currently available scientific literature and their own call to keep red meat consumption to a weekly maximum of 255grams and to virtually avoid all processed meats?

Where are the voices from the Canadian Medical Association and the Dietitians of Canada in opposing a Food Guide that calls only for "limiting" rather than avoiding trans-fats, that includes chocolate milk as a food children should consume more of and that fails to provide practical guidance on calories or sodium choosing instead to provide feckless, duh-inspiring, "choose less" recommendations?

Why aren't all of the folks above standing on the rafters of the House of Commons and demanding the establishment and implementation of evidence-based nutrition in our schools via the development of a national school food program, or championing the protection of Canadian consumers from overly liberal allowances to market foods and nutraceuticals as beneficial to health in the absence of rigorous proof?

It's time we stop turning a blind eye to the things we know are wrong. Diet and weight related illness are killing tens of thousands of Canadians each and every year and will ultimately cripple our health care system. It's gone far past growing a set of proverbial balls, now it's about listening to consciences that should be appalled at silence's fatal consequences. It's important too to point out that I'm not talking here about esoteric, unimportant nutritional minutia, I'm not talking about what I believe versus what you believe, I'm talking about a robust evidence base, I'm talking about the lives of our friends and families and I'm talking about the future of Canadian healthcare as we know it.

If you're already fighting the good fight - thank you. If not, it's time you take a stand. Either way, if you work for a public health agency, a medical NGO, or a nutritional organization, pass this post around and for god's sake, stop accepting policies, programs and positions that make a mockery of the causes you yourselves purport to be championing.

If after reading this you're ready to fight but stuck for causes to champion stay tuned tomorrow when I go over ten nutritional hills worth dying on.

[Hat tip to Quebec nutritionist (it's a protected term there) Jonathan Fontaine for first alerting me to the Coalition's recent press conference. If you're comfortable in French you can read Jonathan's take on it on his blog Le nutritionniste.]

Subscribe via Email

About Me

Family doc, Assistant Prof. at the University of Ottawa, Author of The Diet Fix, and founder of Ottawa's non-surgical Bariatric Medical Institute - a multi-disciplinary, ethical, evidence-based nutrition and weight management centre. Nowadays I'm more likely to stop drugs than start them. You can also follow me on Twitter and Facebook.

Creative Commons License

Disclaimer

Any medical discussion on this page is intended to be of a general nature only. This page is not designed to give specific medical advice. If you have a medical problem you should consult your own physician for advice specific to your own situation. The mission of this blog is to provide readers with critical appraisals of nutrition and weight related claims, products and policies so as to allow readers to make more informed decisions in those areas.

The author will not post anything related to any of his patients personal medical histories or circumstances without their explicit written permission.

Emails are not published with comments and no personal information is collected by this website. If you leave a comment you can choose to delete it. The only comments I actively delete are those containing profanities or spam (links to commercial websites whereby the link is not contextual with the content of the comment). I track comments multiple times daily. Should you choose to leave a comment please provide sources to any health or medical claims made and of course do not post any information that is not true and correct to your knowledge. Unless otherwise specified, please assume any commentator is a non-health professional. You and I are no different - we must both strive to always be respectful and honest.

This site is hosted free of charge by Google's Blogger platform and is intended not only for allied health professionals but also for interested members of the general public.

If you have any concerns feel free to email me at yonifreedhoff [{@}] gmail dot . com